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• <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR n pp <br /> I/Iry",�� ./�•�y-/ � CHECK If BILLING ADDRESS <br /> FACILITY NAME �' <br /> SITE ADDRESS �J /r/(��ggq/.L(. � QI �) //'jam <br /> Street Numbar Mon ' " Street N / r� / I ' - ' NZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr APN# LAND USE APPLICATION# <br /> (Oc(f) 40 1 —0 339- �'li og4k Z$OI <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> 1 I DZ oIL <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS Er <br /> BUSINESS NAME P ExT. <br /> HOME or MAILIN ADDRESS rt 62 K FAR# <br /> p.J<-�✓ / (off`�1 4-eP l� ¢' <br /> CITY 112"J STATE ZIP "a03- <br /> BILLING AC OWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this appli to and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �0 DATE: 7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT /C <br /> If ADPL/CANT is not the BILL/NG PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. L <br /> TYPE OF SERVICE REQUESTED: �(,�W0, • w5 , PAYAWNT <br /> COMMENTS: <br /> RECE4VF- <br /> SEP 17 2013 <br /> SAN UNTY <br /> E JOAQUIN ROMENTO ENT <br /> ACCEPTED BY: l,(a,r <br /> EMPLOYEE#: ATE: <br /> ASSIGNED TO: 2 S EMPLOYEE M DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: ( O P I E: 72E2? <br /> If <br /> Fee Amount: '} p' Amount Paid '3.J 7�•n Payment Dated 9/711-5 <br /> Payment Type Invoice# Check# Received B ' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />